Undetected traumatic diastasis of cranial sutures: a case of child abuse

Imaging Findings in Pediatric Accessory Cranial Sutures using 3D CT Reconstruction: Fracture or Rudimentary Suture

Objective: Although accessory sutures are considered to be relatively rare, the consequences of a missed diagnosis are profound. Distinguishing between accessory sutures and cranial fractures can be difficult, especially in cases of suspected non-accidental trauma. High-resolution imaging is the best way to discern between two- and three-dimensional computerized tomography (3D CT) is considered the preferred method for evaluation. The goal of this study was to determine the impact of 3D CT scans in distinguishing between accessory sutures and cranial fractures in suspected child abuse cases in a rural community and the importance of early detection in such cases, as well as call attention to the consequences of initial misinterpretation. Materials and methods: The researchers conducted a retrospective chart review of all pediatric patients diagnosed with cranial fractures (265 in total) at University Medical Center between May 30, 2016, and May 30, 2021. Initial computed tomography (CT) scans and subsequent 3D CT scans were evaluated for each patient that fit the inclusion criteria, 13 in total. Patients were then categorized into two groups based on the final diagnosis on the radiology report: accessory cranial suture or cranial fracture. Once these patients were identified, the etiology and structural components of each were evaluated, and the key differences were highlighted. Results: Our results showed that, of the 11 cases of suspected non-accidental trauma, six were finally diagnosed with accessory sutures with the use of 3D CT scans, and of those six, four were diagnosed with cranial fractures from the initial CT scan report due to a similar presentation and asymmetric nature. Conclusion: Discerning between fracture and accessory suture is essential in evaluating pediatric patients presenting with signs of cranial fracture due to the increased risk of misinterpretation that can lead to severe legal consequences considering that cranial suture variants may mimic intentional injury and be mistaken for child abuse, causing significant distress for patients and their families.

Estimation of Late Postmortem Interval: Where Do We Stand? A Literature Review

Estimating time since death can be challenging for forensic experts, and is one of the most challenging activities concerning the forensic world. Various methods have been assessed to calculate the postmortem interval on dead bodies in different stages of decomposition and are currently widely used. Nowadays, the only well-recognized dating technique is carbon-14 radioisotope measurement, whereas other methods have been tested throughout the years involving different disciplines with different and sometimes not univocal results. Today, there is no precise and secure method to precisely determine time since death, and late postmortem interval estimation remains one of the most debated topics in forensic pathology. Many proposed methods have shown promising results, and it is desirable that with further studies some of them might become acknowledged techniques to resolve such a difficult and important challenge. The present review aims at presenting studies about the different techniques that have been tested in order to find a valuable method for estimating time since death for skeletal remains. By providing a comprehensive overview, the purpose of this work is to offer readers new perspectives on postmortem interval estimation and to improve current practice in the management of skeletal remains and decomposed bodies.

Assessment of Cervical Skeletal Trauma: The Synergistic Contribution of Forensic and Clinical Medicine to a Case of Corpse Concealment

Fatal neck injuries represent a major challenge in forensic pathology because the anatomical complexity and high variability of neck structures make it often extremely difficult to differentiate true pathological findings from artifacts at autopsy. This topic becomes even more relevant when the forensic pathologist is required to make a pathophysiological evaluation of bone fractures in the absence of soft tissue to support the diagnosis. We report a case of unidentified, stone-covered, skeletonized human remains found within a pit below an abandoned building with bony lesions of the cervical spine and ribs, including a full-thickness fracture of the right lateral mass of the atlas (C1). After a careful study of the fractures was carried out by screening forensic literature and anthropological studies, clinical neurosurgical expertise was called upon to provide a reliable explanation. A rapid and violent twisting of the neck in the opposite direction from the fracture site by an attacker who pinned the victim's torso is the scenario that most likely occurred in our case. This case report shows that the diagnosis of cervical spine injuries in skeletal remains should be the result of a multidisciplinary approach that integrates forensic, anthropological, and clinical expertise.

Cranial Suture Evaluation in Pediatric Head Trauma: Importance in Differentiating Abusive From Accidental Injury

OBJECTIVES

Pediatric skull fracture association with the cranial sutures (crossing, widening, or contacting 2 or more cranial sutures) is suggestive of abusive injury. We studied the efficacy of head computed tomography (CT) versus skull radiographs in identifying pediatric skull fracture association with cranial sutures and reviewed head CT literature recommendations for pediatric head trauma.

METHODS

Retrospective review was performed of skull radiographs and head CT at a tertiary care, free-standing children's hospital (2012-2019). Statistical 2-proportion Z test determined efficacy of head CT versus skull radiographs in assessing cranial suture involvement with fractures.

RESULTS

Forty-seven children with 56 abusive skull fractures and 47 children with 54 accidental skull fractures were evaluated, ages 1 to 36 months. Of the 110 total skull fractures evaluated, 51 abusive and 41 accidental skull fractures had terminal ends contacting cranial sutures for a total of 92 (84%). Twelve abusive fractures (24%) crossed sutures; no accidental fractures crossed sutures (P < 0.01). Of the 12 abusive cases with skull fractures that crossed sutures, 7 were definitively identified only on CT (P < 0.01). Widened sutures were documented in 4 (8%) of the abusive cases with skull fracture; none in the accidental cases. All 4 of these cases were equally identified on both skull radiography and CT imaging. In 21 of 47 abusive versus 5 of 47 accidental cases, CT identified skull fractures lines that extended to cranial sutures that were not definitive on skull radiography (P = 0.00022).

CONCLUSIONS

Cranial suture involvement with pediatric skull fractures is common. Head CT significantly aided in the identification of skull fractures contacting and crossing cranial sutures in abusive cases, supporting eliminating concurrent skull radiographs.

Infantile acute subdural hemorrhage probably caused by injury to the diploic channels

A 6-month-old, previously healthy boy hit the right frontal region of his head against the corner of a plastic toy box. At presentation, a small area with scalp discoloration was noted in the right frontal region. Head computed tomography at the level of discoloration revealed an intracranial hematoma, 5 mm in maximal thickness, below the coronal suture. In addition, there were bony bridges connecting the frontal and parietal bones. Furthermore, a linear crack was found in the diploe of the frontal bone in contact with the coronal suture. Cerebral MRI confirmed linear hyperintensity between the inner tables. We assumed that a kind of ping-pong ball fracture was caused by the head blow, centering on the coronal suture, resulting in rupture of contacting diploic channels and tear of the dura mater, and forming a subdural hematoma. Acute subdural hemorrhage may be caused by an insignificant blow to the coronal suture in infantile patients with underdeveloped cranial bones and sutures, accompanied by subtle external findings.

Pediatric Skull Fractures Contacting Sutures: Relevance in Abusive Head Trauma

OBJECTIVE. The purpose of this study was to assess the incidence of pediatric skull fractures contacting cranial sutures in abusive versus accidental trauma. MATERIALS AND METHODS. A retrospective review was conducted of head CT studies performed for pediatric head trauma at a free-standing tertiary care children's hospital from 2012 to 2019. Statistical odds ratios were evaluated to assess the significance of skull fracture extension to sutures in abusive versus accidental injury. A two-proportion Z-test was used to determine the statistical significance of suture type contacted by skull fractures in accidental versus abusive injury. RESULTS. The records of 47 children with 57 abusive skull fractures and 47 children with 54 accidental skull fractures were evaluated. The patients were 1-36 months old. Fifty-one abusive skull fractures (89%) terminated in contact with a cranial suture; 35 of the 51 (69%) touched two or more sutures, and 12 touched three or more sutures. Forty-two of the 54 (78%) accidental skull fractures contacted a suture; only 3 of the 42 (7%) touched two sutures, and none touched more than two sutures (odds ratio, 28.4 [95% CI, 7.6-105.9]; p < .001). In the abusive fractures, the suture most commonly contacted by a fracture line was the lambdoid (43%; p < .04), followed by the sagittal (23%), coronal (21%), temporal-squamous (12%), and metopic (1%) sutures. There was no statistical difference in which suture was contacted by fracture lines in accidental cases. CONCLUSION. Skull fracture contacting cranial sutures is common in abusive and accidental pediatric head trauma. However, that a fracture contacts two or more cranial sutures is an imaging finding not previously described that has a significantly higher association with abusive than with accidental head injury.

Coronal and sagittal suture lengths as novel measurements for sex identification in a sample from the Egyptian population

Sex estimation from isolated or fragmented bones is a cornerstone in medicolegal identification. The current study aimed to estimate sex from the lengths of the coronal and sagittal sutures in a sample of Egyptians. The study was performed on a total of 80 adult cadavers (48 males and 32 females) during a routine autopsy. After exposure of the skull vault, the lengths of the coronal and sagittal sutures were measured using a thread and a graduated scale. The mean length of the coronal suture was significantly higher in males (24.8 ± 1.4 cm) than in females (22.7 ± 1.4 cm). The mean length of the sagittal suture was significantly higher in males (11.9±1.6 cm) than in females (10.8±1.6 cm). This study used the lengths of the coronal and sagittal sutures as measurements for sex estimation for the first time. Receiver operator characteristic (ROC) curve analysis revealed that the combined coronal and sagittal sutures lengths were the best sex discriminator (AUC= 0.859), followed by the coronal suture length (AUC= 0.855), and sagittal suture length (AUC= 0.697). Moreover, regression analysis was performed for sex determination; the highest accuracy was obtained by an equation that included the lengths of the coronal and sagittal sutures together (76%); followed by the coronal suture length (75%); then the sagittal suture length (71%). These measurements are easily obtained during a conventional autopsy and this method of sex estimation is cost effective when compared to radiological and DNA analysis. Moreover, the measurements can be carried out on dry skulls as long as the vault has identifiable landmarks.

Posttraumatic Cranial Suture Diastasis in Pediatric Temporal Bone Fractures

OBJECTIVE

Only a handful of case reports exist describing posttraumatic sutural diastasis in the calvarium and none report concurrent temporal bone involvement. We aim to describe diastasis along the temporal bone suture lines in the setting of temporal bone trauma and to identify clinical sequelae.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary Level 1 trauma center.

PATIENTS

Forty-four patients aged 18 and younger who suffered a temporal bone fracture from 2013 to 2018 were identified. Diastasis and diastasis with displacement at the occipitomastoid, lambdoid, sphenosquamosal and petro-occipital sutures, and synchondroses were determined.

MAIN OUTCOME MEASURES

The presence of temporal bone suture and synchondrosal diastasis following temporal bone trauma. Diastasis was defined as sutural separation of a distance greater than 1 mm in comparison to the contralateral side.

RESULTS

Using our diastasis diagnostic criteria, diastasis occurred in 41.5% of temporal bone fractures. Transverse fracture types were significantly associated with diastasis (p ≤ 0.001). Lower Glasgow Coma Scale (GCS) and loss of consciousness (LOC) were associated with the presence of diastasis with displacement and diastasis (p = 0.034 and p = 0.042, respectively). Otic capsule violation was more common in fractures with diastasis but did not reach statistical significance. There were two cases of cerebrospinal fluid otorrhea and three deaths in cases that featured diastasis.

CONCLUSION

Our findings indicate that diastasis is a positive predictor for higher disruptive force injuries and more severe outcomes and complications. Posttraumatic temporal bone suture diastasis may represent a separate clinico-pathologic entity in addition to the usual temporal bone fracture classification types.

Homicide and concealment of the corpse. Autopsy case series and review of the literature

INTRODUCTION

The concealment of the body following a homicide undermines different moments of the forensic and medico-legal investigations. The aim of the present study is to provide an overview of the literature and the forensic casuistry of the Institute of Legal Medicine of Padova for analyzing and discussing diverse methodological approaches for the forensic pathologist dealing with covered-up homicides.

MATERIAL AND METHODS

A literature review, updated until September 2019, was performed, and a literature pool of forensic cases was built. In-house cases were included by conducting a retrospective analysis of the forensic caseworks of Padova of the last 20 years. Data regarding epidemiology, methodology of assessment, methods of concealment, and answers to medico-legal issues were extracted for both data sets.

RESULTS AND DISCUSSION

Seventy-eight papers were included in the literature review (78.2% being case reports or case series, 17% retrospective studies, and 6% experimental studies or reviews). Literature and in-house data sets consisted of 145 and 13 cases, respectively. Death scene investigation, radiology, toxicology, and additional analyses were performed in 20-54% of literature and 62-77% of in-house cases. Cover-up by multiple methods prevailed. Death was caused by head trauma in about 40% of cases (both data sets), strangulation in 21% of literature, and 7% of in-house cases, and was undetermined in 17% of literature and 7% of in-house cases.

CONCLUSIONS

The methodology of ascertainment should be case-specific and based on a multidisciplinary and multimodal evaluation of all data, including those gained through novel radiological and/or analytical techniques.